In Switzerland, the development of advanced nursing practice roles started in the late 1990s (Table 1), with the introduction of the Master's of science in nursing courses at university level (Keinath, 2023). During the same period, roles for clinical nurse specialists, focusing primarily on inpatient settings, were also developed (Spirig et al, 2001). To date, more than 1000 advanced practice nurses (APNs) have graduated in Switzerland (Bischofberger et al, 2020). Approximately 15 years ago, nurse practitioners began working in clinical settings, initially focusing on acute care (Steinbrüchel-Boesch et al, 2017), and later expanding into family practice (Schlunegger et al, 2022). Around the same time, universities began offering Master's of science in nursing courses focused on nurse practitioners. At present, nurse practitioner role development and implementation projects are underway in various inpatient and outpatient settings, and some of them have been implemented and evaluated successfully (von Dach et al, 2022). However, the implementation of new roles often focuses on the introductory phase and short-term impact, with little attention to their long-term sustainability.
| Year | Master's of science in nursing/doctoral programmes | Focus | Institutions |
|---|---|---|---|
| 1997 | Start of a joint Master's of science in nursing | Research | WE'G (Institute of further education in healthcare), Switzerland, in collaboration with the University of Maastricht, Netherlands |
| 2000 | Master's of science in nursing; PhD in nursing | Research, advanced practice nursing | University of Basel, Institute of Nursing Science, Switzerland |
| 2009 | PhD in nursing | Research | University of Lausanne, Institute of Higher Education and Research in Health, Switzerland |
| 2009 | Master's of science in nursing | Research, advanced practice nursing | Careum, Kalaidos University of Applied Sciences, Zurich, Switzerland |
| 2010 | Master's of science in nursing | Advanced practice nursing | University of Lausanne, Institute of Higher Education and Research in Health in collaboration with the University of Applied Sciences of Western Switzerland |
| 2010 | Master's of science in nursing | Advanced practice nursing | Universities of Applied Sciences Bern, Zurich and St Gall (joint curriculum), Switzerland |
| 2018 | Master's of science in nursing | Nurse practitioner | University of Lausanne, Institute of Higher Education and Research in Health, Switzerland |
| 2019 | Master's of science in nursing | Programmes for nurse practitioner, clinical nurse specialist and research | Bern University of Applied Sciences Health, Switzerland |
| 2019 | Master's of science in nursing | Research, advanced practice nursing | Zurich University of Applied Sciences, Switzerland |
| 2019 | Master's of science in nursing | Research, advanced practice nursing | OST University of Applied Sciences, St Gallen, Switzerland |
| 2019 | Master's of science in nursing | Research, advanced practice nursing | SUPSI University of Applied Sciences Ticino, Switzerland |
| 2021 | Master's of science in nursing | Psychiatric mental health nurse practitioner | Bern University of Applied Sciences Health, Switzerland |
Background
There is a lack of literature regarding sustainability in newly implemented nurse practitioner roles. However, both hindering and supporting factors concerning the sustainability of the APN roles have been reported at individual and structural levels. Barriers for individual nurse practitioner roles include a lack of self-identification with the role (Wood et al, 2021), lack of self-confidence (Giles et al, 2017), lack of role models and expert support (Canadian Nurses Association, 2019), as well as isolation when the role is in a solitary position in a hospital (Wood et al, 2021). The lack of opportunities to apply the skills acquired as an nurse practitioner also leads to dissatisfaction (Schirle et al, 2020; Busca et al, 2021).
Structural factors impacting the sustainability of the role occur at both the organisational and government levels. At the organisational level, the misunderstanding of the nurse practitioner role and limitations on competencies and the scope of practice are barriers to sustaining roles (Giles et al, 2017; Busca et al, 2021; Rakhab et al, 2021). The hierarchy in healthcare, unresolved areas of competency, high workload and poor service planning are other reported issues affecting the sustainability of the role (Maten-Speksnijder et al, 2015; Rakhab et al, 2021). At the government level, the lack of national regulation for nurse practitioner roles is a barrier to the sustainability of the role (Rakhab et al, 2021; Wood et al, 2021).
These organisational and government issues are interconnected. Regarding national regulation, stakeholders within institutions rely on regulatory frameworks to guide their understanding of competencies and the scope of practice for nurse practitioners. Additionally, a lack of financial resources to support the continuation of permanent nurse practitioner positions has been reported (DiCenso et al, 2010; Schirle et al, 2020; Torrens et al, 2020). Finally, nurse practitioners report a lack of public recognition of their role and the contribution APNs make to patient care and healthcare outcomes (Wisur-Hokkanen et al, 2015; Schirle et al, 2020). In the following section, the authors present a case scenario of a hospital nurse practitioner to illustrate the challenges related to role sustainability.
The case: a pilot project to introduce a nurse practitioner into a surgical unit
A new nurse practitioner role was implemented over a 1-year period, and after this time, the decision was made to maintain the role as part of the care team. The role evaluation was conducted using a mixed-methods design (von Dach et al, 2022), which included analysis of care indicators, time of dismissal, inter-professional collaboration, focus groups and interviews.
The evaluation yielded positive results, including a shorter length of stay, improved patient and staff experiences, enhanced inter-professional collaboration and no change in discharge time. These outcomes led the management team to integrate the role into routine operations.
Positive feedback was received from both the nursing staff and the rest of the surgical team. The nurse practitioner covered the unit daily from 7:00–17:00, over 90% of the time. The amount of overtime was limited to conform with the labour regulations in Switzerland. The nurse practitioner roles included tasks typically carried out by physicians, such as conducting initial examinations and patient visits, delegated prescribing of medications and preparing discharge reports (signed by the senior doctor). However, the nurse practitioner was not responsible for night, weekend or emergency services.
The nurse practitioner reported disillusionment with the role after approximately 3 years. She felt there were limited opportunities for personal development, and the scope of her responsibilities had not been expanded, despite the increasing workload, which had reached its maximum capacity. Additionally, she was dissatisfied with service planning and faced difficulties in being compensated for overtime. During this period, a change in the chief medical officer left her feeling unsupported. As a result, she ultimately decided to resign from the position.
Case analysis
The case demonstrates the highly successful implementation of the nurse practitioner role, which reflects the typical approach to introducing APNs in Switzerland. All participants expressed enthusiasm for the nurse practitioner role, and the primary goal was to integrate it into the surgical unit, which proved successful during the first two years.
During this period, the structures, processes and interdisciplinary team were stable, with a high level of support for the role. However, after the change in the chief medical officer, it became evident that the success of the role depended heavily on the relationship between the physician and the nurse practitioner. Key processes, such as the scope of practice and the competencies of the nurse practitioner, were informal and not part of the organisational policy. Instead, they relied on the individual in the chief medical officer's position.
The lack of clarity about working hours initially posed no problem, because the nurse practitioner was enthusiastic about her job. However, no other nurse practitioner was hired to cover for absences over the 3-year period. As the only nurse practitioner in the hospital, she felt isolated, and in her absence, a physician would perform her duties. While this was not a problem initially, it became increasingly burdensome for the nurse practitioner in her third year. Furthermore, there was no possibility for personal and professional development in her role. The nurse practitioner became an expert in treating patients with the specific diagnosis she focused on. However, she noticed that the physicians around her advanced further in their careers and had opportunities for continued professional development, while such opportunities were not available to her. In conversations with her superiors, the nurse practitioner attempted to clarify her position, express her needs and share her feelings of discouragement. Unfortunately, she did not feel supported in finding a solution.
Discussion
The isolation of an nurse practitioner when in a sole role in a hospital, as seen in this case study, has been reported previously (Wood et al, 2021). To ensure sustainable implementation, more than one nurse practitioner should be hired to cover clinical care, allowing each nurse practitioner to attend educational events or engage in research activities. Healthcare institutions need to invest in role development for nurse practitioners; without such investment, nurse practitioners may leave for organisations that offer these opportunities.
The integration of a team of nurse practitioners would allow new nurse practitioners to receive feedback on their practice, foster socialisation and share experiences. This approach could support role identification and boosts self-confidence. Leaders must take these factors into account when implementing new nurse practitioner roles, planning for mentors within hospitals or facilitating connections with other organisations for networking.
Processes for care delivery and standardised competencies for nurse practitioners must be established within the system and cannot rely solely on individual enthusiasm for the new role. Integration into the organisational structure and team hierarchy, processes for managing high workloads and planning for effective service delivery should be addressed at the onset of implementation.
While these factors may not significantly affect the nurse practitioner initially, they can become critical over time. By clarifying such processes early on, some of the main hindering factors (Maten-Speksnijder et al, 2015; Rakhab et al, 2021) can be mitigated, establishing better preconditions for a sustainable role. It is crucial to involve all stakeholders—including leaders, healthcare team members, physicians and nurse practitioners—when clarifying new roles. An inclusive and participatory approach to defining new processes can help prevent disappointment and reduce the potential for costly turnover.
In this scenario, the success of the role was heavily reliant on the chief medical officer. It is important to share frequent information and evidence with various groups within the organisation, whenever possible, to gain widespread support and ensure a clear understanding of the value of the APN role.
Recommendations for clinical practice are as follows: